ATI RN Maternal Newborn 2023/24 1st Attempt & Retake -Nurselytic

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ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions

Extract:

A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination

1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.


Question 1 of 5

Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.

Potential Nursing Action Indicated Contraindicated
Educate the parents to begin range of motion exercises on the affected arm after 1 week.
Assess for grasp reflex in the affected extremity.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
Instruct parents to limit physical handling for 2 weeks.

Correct Answer:

Rationale:
Correct
Answer:


Rationale:
- Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated as it promotes joint mobility.
- Assess for grasp reflex in the affected extremity is contraindicated as it can cause discomfort and potential harm.
- Immobilizing the arm across the abdomen is contraindicated as it can restrict circulation and hinder development.
- Instructing parents to limit physical handling for 2 weeks is indicated to prevent excessive stress on the affected arm.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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